Carlo Rebuffat

Major pulmonary resections: pneumonectomies and lobectomies.

We report on our experience in 20 patients who underwent major thoracoscopic pulmonary resections between October 1991 and November 1992. These consist of 2 left pneumonectomies, 17 lobectomies, and 1 segmentectomy. The indications were strictly limited to benign pulmonary diseases and stage I (TNM) primary lung cancer. A hilar lymphadenectomy was performed in all cases of malignancy. Our surgical technique is described. Our findings demonstrate the feasibility of performing major video-assisted thoracoscopic pulmonary resections, even though the definite role of this procedure in the management of lung cancer must still be defined.

Videothoracoscopic staging and treatment of lung cancer.

Videothoracoscopy, routinely performed as the initial step of an operation, opens interesting opportunities for both the operative staging and treatment of lung cancer. Videosurgical maneuvers ensure thorough exploration of the cavity, thus avoiding unnecessary exploratory thoracotomies, confirming resectability of the lesion by open or, in selected cases, by a direct video-assisted approach. We report our experience of 155 patients submitted to videothoracoscopic operative staging between October 1991 and January 1994. Videothoracoscopic operative staging showed unresectability in 13 patients (8.3%) due to preoperatively unexpected (10 patients) or suspected conditions (3 patients). The remaining 142 patients were divided by staging of the lesion and general conditions into three groups. Group A consisted of 13 elderly patients with small peripheral tumor who could not tolerate lobectomy and who underwent thoracoscopic wedge resection. Group B consisted of 63 patients with peripheral clinical T1 N0 or T2 N0 tumor. Fifty-two lobectomies and 4 pneumonectomies were carried out thoracoscopically. Seven conversions to thoracotomy were necessary due to technical problems. The postoperative course was uneventful in 51, 5 had prolonged air leakage, and a bronchial fistula developed in 1 because of positive-pressure postoperative ventilation. Group C consisted of 66 patients with stage II or IIIa neoplasm. Thoracotomy after thoracoscopy proved unresectability in 4, whereas 62 were submitted to a radical pulmonary resection. In the literature the incidence of exploratory thoracotomies for conditions missed by preoperative staging still remains high. After adoption of videothoracoscopic operative staging we reported a 2.6% exploratory thoracotomy rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic Treatment of Bronchopleural Fistulas

BACKGROUND Bronchial fistula is one of the most serious complications of pulmonary resection. METHODS We present an endoscopic treatment that consists of multiple submucosal injections of polidocanol-hydroxypoliethoxidodecane (Aethoxysklerol Kreussler) on the margins of the fistula using an endoscopic needle inserted through a flexible bronchoscope. RESULTS From 1984 to 1995, 35 consecutive nonselected patients with a postresectional bronchopleural fistula were treated. All 23 partial postpneumonectomy or postlobectomy bronchopleural fistulas, ranging from 2 to 10 mm in diameter, healed completely. This did not occur in the 12 total bronchial dehiscences. No complications occurred due to the injection of the drug. CONCLUSIONS In our opinion this treatment can be considered a valid therapeutic approach, as it is simple, safe, scarcely traumatic, and inexpensive, particularly considering that, in patients in stable condition, it can be performed as an outpatient treatment.

Tracheal sleeve pneumonectomy for bronchogenic carcinoma

Abstract For a long time, primary tumors arising less than 2 cm distal to the carina have presented a contraindication to surgical excision. Tracheal sleeve pneumonectomy technique allows carinal resection and reconstruction but still carries considerable postoperative complications. From 1983 to 1992 we performed 27 right tracheal sleeve pneumonectomies and one left. Fourteen patients had N0 nodes, nine had N1, and five had N2. No anastomotic complications, either fistula or stenosis, were observed. Successful outcome depends on meticulous attention to surgical details and careful anaesthetic management with a new ventilation tube. One patient died on the twenty-second postoperative day from myocardial infarction. Complications included pneumonia (one), vocal cord paresis (two), and pleural empyema without bronchial fistula (one). Conservative treatment allowed complete recovery from all complications. There are seven patients alive at 4 years after operation and one at 5 years. Six patients have been disease-free for between 1 and 32 months. Two patients died free of disease at 13 and 42 months. Two patients died of mediastinal recurrence and 10 of distant metastases within 6 and 54 months. (J THORAC CARDIOVASC SURG 1994;107:13-8)

Videothoracoscopic treatment of oesophageal leiomyoma

BACKGROUND Oesophageal leiomyomas are usually so easily removed that thoracotomy seems out of proportion and thoracoscopic removal is therefore highly desirable. METHODS Out of a total of 1003 thoracoscopic operations undertaken between July 1991 and December 1996, seven patients underwent thoracoscopic removal of oesophageal leiomyoma. All of them had been preoperatively studied by oesophagogastroscopy and computed tomographic scanning of the chest which had confirmed the presence of a lesion with benign features. The surgical technique required intubation with a double lumen tube. Operative access was gained through the right chest via three ports and a small utility thoracotomy in the inframammary sulcus. The mean operating time was 120 minutes. RESULTS Conversion to open thoracotomy was necessary in one case with a very large horseshoe-shaped leiomyoma which was firmly adherent. The mean postoperative hospital stay was seven days. No intraoperative deaths or postoperative complications occurred. CONCLUSIONS The simplicity and safety of the thoracoscopic approach, combined with reduced surgical trauma and postoperative pain and functional and cosmetic advantages, make this technique the approach of choice for the removal of oesophageal leiomyomas.

A new mechanical device for circular compression anastomosis. Preliminary results of animal and clinical experimentation.

The authors report the preliminary results obtained in animal and clinical experimentation of a new mechanical device for circular anastomosis which they have developed. It is a gun that places an apparatus consisting of three polypropylene rings that, through the compression among them of the severed edges of the bowel, realize a sutureless anastomosis and are spontaneously evacuated. Fifty-eight colonic anastomoses were performed in dogs with this device; 23 stapled colonic anastomoses were also executed concurrently. Forty-four animals underwent a relaparotomy to remove the colonic specimen containing the anastomoses. Bursting pressure and the histologic features of the anastomoses were evaluated at different time intervals after operation. A good healing of all compression anastomoses was observed, thereby allowing them to initiate the experience in humans. Thirteen anastomoses (6 colorectal extraperitoneal, 1 colorectal intraperito-neal, 5 colocolonic, 1 ileorectal) were performed at the 1st Surgical Department, Milan University. One subclinical leakage (7.7%) spontaneously healed in a few days. No stenoses were observed.

Clinical application of a new compression anastomotic device for colorectal surgery

Fifty-six patients underwent large bowel anastomosis by the compression anastomotic device developed by the authors from May 1986 through December 1988. Operations performed were 40 left hemicolectomies or anterior resections of the sigmoid and rectum, 7 left colon resections, 7 right hemicolectomies, and 2 total colectomies. Twenty-one anastomoses were done on the extraperitoneal rectum, in 7 cases less than 4 cm from the anal verge and in 9 cases between 4.5 and 8 cm. Five intraoperative diverting colostomies were done (9%). The rings of the device were evacuated postoperatively after a mean of 11 days with little or no discomfort. Operative mortality was 1.8% (one patient died of myocardial infarction). Anastomotic complications were one (1.8%) clinical and one (1.8%) subclinical leak. Mean postoperative hospital stay was 14 days. This initial clinical experience shows that the anastomotic device is reliable.

A new anoscope for transanal surgery.

BACKGROUND Although stapled mucosectomy has several advantages over hemorrhoidectomy for hemorrhoidal prolapse, complications such as hemorrhage, pain, and life-threatening pelvic sepsis may occur, often due to poorly executed purse-string suture. We describe a simple new anoscope that makes it easy to correctly perform and position the purse-string suture that is an integral part of stapled mucosectomy. METHODS The apex of the middle part of the new anoscope consists of digitiform projections separated by spaces. After insertion of the instrument into the anus, the inner part is removed, allowing strips of rectal mucosa to protrude through the spaces between the digitiform projections. The purse-string suture is made through these protrusions. The suture catches the mucosa and submucosa but not the deeper muscle layer, which does not protrude through the spaces. CONCLUSION Preliminary histologic studies in the pig suggest that the design of the anoscope prevents inclusion of the muscular layer in the pursestring.

Technique of thoracoscopic retrieval of the lung

Extraction of a resected specimen after a thoracic minimally invasive operation presents different problems depending on the amount of parenchyma removed. After a major pulmonary resection (lobectomy or pneumonectomy), the size of the specimen always requires a minimal thoracotomy incision of at least 5–6 cm. In the case of neoplasms it is mandatory to adopt precautions in order to protect the wound edges from possible tumoral seeding during the extraction. The authors, based on their personal experience of 545 video-thoracoscopic procedures, discuss the problems of retrieving the specimens after video-endoscopic resections and describe techniques and precautions which must be taken to extract the resected tissue safely.